SAN DIEGO — It is clear that cancer survivors who undergo hematopoietic cell transplant (HCT) can experience long-term side effects years after treatment, but a new study shows just how frequent and how severe those sequelae can be.
Researchers from City of Hope Comprehensive Cancer Caenter reported here at the ASH Annual Meeting that the burden of long-term physical and emotional morbidity in survivors at 10 years or more is substantial, with three times the incidence of chronic health conditions in survivors compared with their siblings.
The lead author of the study presented as Abstract 841, Can-Lan Sun, PhD, Associate Research Professor of Epidemiology and Survey Research, said health care providers should be made aware of the potential for morbidity, but that it is also important that patients and their families should also be advised so they might plan for post-HCT care, even many years after HCT.
There are economic implications as well, as long-term morbidity results in a high utilization of specialized health care. She and her colleagues previously demonstrated that morbidity increases with increasing time after HCT (Sun CL: Blood 2010;116:3129-3139), but the burden of morbidity in patients who survive extended lengths of time after HCT and the consequent health care needs of these survivors had not been studied.
The senior author on both studies is Smita Bhatia, MD, Chair and Professor of Population Sciences and Director of the Center for Cancer Survivorship.
Chronic conditions resulting from HCT can include hearing loss not able to be corrected by a hearing aid, blindness, need for dialysis support, rectal or anal strictures, cirrhosis, coronary artery disease, congestive heart failure, stroke, need for joint replacement, diabetes, and subsequent cancers, Sun said.
In the retrospective study reported at ASH, she and her colleagues evaluated the risk of chronic health conditions and psychological health of 366 HCT survivors 10 years or more after treatment, and of 309 siblings as well. Health conditions were graded from mild to life-threatening to death due to a chronic health condition.
The mean age at HCT was 22 (range of 0.4 to 59.8) and at study participation was 37 (range of 11 to 72). The mean length of follow-up was 15 years.
Primary diagnoses included acute myelogenous leukemia (28%), acute lymphocytic leukemia (17%), chronic myelogenous leukemia (17%), non-Hodgkin's lymphoma (11%), aplastic anemia (11%), Hodgkin lymphoma (7%), and other diagnoses (9%).
Total body irradiation-based conditioning was given to 72% of the patients.
Triple the Rate of Chronic Health Conditions
Three times as many HCT survivors reported at least one chronic health condition compared with siblings—74% vs. 29%, Sun reported.
And 25% of the cancer survivors reported severe/life-threatening conditions compared with only 8% of the siblings.
Commonly reported severe/life-threatening chronic health conditions included myocardial infarction, stroke, blindness, diabetes, musculoskeletal problems, and subsequent malignancies.
The cumulative incidence of any chronic health condition for the cancer survivors at 15 years was 71%, and the incidence of severe-life-threatening conditions or death due to a chronic condition was 40%, Sun reported.
“And HCT survivors were 5.6 times as likely to develop a severe/life-threatening condition compared with age- and sex-matched siblings,” she said.
The cumulative incidence of severe/life-threatening conditions did not differ by type of HCT. While the prevalence of anxiety and depression were comparable between survivors and siblings, survivors were 2.7 times more likely to report somatic distress.
Among HCT survivors, female gender, low household income (less than $20,000), and poor self-rated health status were associated with an increased risk for somatic distress.
“Fortunately, 90% of HCT survivors carried health insurance coverage, because a high proportion needed ongoing specialized medical care,” Sun said. “And 69% of the HCT survivors reported cancer or HCT-related visits at an average of 15 years after HCT.”
Over, But Not Really Over
“Transplant medicine has been going on for decades. Many people are surviving these procedures, and we are constantly working in the short term to make the procedure better, but it is important that we look at the long-term effects on these survivors as well,” said the moderator of a news conference at the meeting on key transplant studies, Stephanie J. Lee, MD, Professor of Medicine at the University of Washington School of Medicine in Seattle and a transplant specialist at Fred Hutchinson Cancer Research Center.
“We have many more survivors than we used to, and we are very thankful for that, but it is important to realize that once a transplant is over, it's not really over, and there are long-term effects either because of the transplant procedure or because of the chemotherapy.”
She said patients need to be aware that they are at higher risk for some of these long-term effects, and that they need to seek preventive and survivorship care, and may need long-term monitoring.